NYAPRS Note: While Ohio providers wait for the release of state data on the effectiveness of their 5 county Health Homes pilot, anecdotal reports indicate important progress. One provider described a 30% increase in linking consumers to primary care and in increased BH provider awareness of and focus on consumers’ health related issues. Another converted a vacant church to a wellness center that features a focus on fitness and diet.

At the same time, the state is delaying making the program statewide until provider rates are adjusted upwards to pay for the increased costs of serving higher needs individuals, with risk adjusted rates as one option. Agencies are also requiring increased infrastructure to collect data to meet the state’s 31 outcome measures.

New York’s statewide health home initiative is showing similar examples of improved consumer health outcomes and integration but also has required a review of rate adequacy. We are also awaiting federal approval of our waiver application that would greatly boost provider infrastructure, especially in the area of IT and outcome data collection.

Ohio to Recalibrate Regulations on Health Homes Before Expansion

Mental Health Weekly September 3, 2013

The state of Ohio’s yearlong experience with an effort to coordinate mental and physical healthcare through a health homes construct offers a vivid example of the challenges and opportunities inherent in any attempt to redefine service delivery using the principles of health reform.

While there is broad consensus that a Medicaid health homes project will ultimately improve enrollee health outcomes and should be implemented statewide, the best path for getting there hasn’t proven to be so clear. State officials and stakeholders met last month and concluded that more planning needs to be done before proceeding with a statewide implementation that originally had been scheduled to take place this October.

Pilot health home initiatives in five Ohio counties have uncovered some promising information about clients’ access to primary care services and wellness activities to help manage chronic illnesses, but formal data on outcomes in the pilot communities still have not been released. The provider community originally had heard that some data would be available by last spring.

“We originally started with 31 outcome measures in the Phase 1 pilot. Building the infrastructure has been a challenge,” Teresa Lampl, associate director of the Ohio Council of Behavioral Health and Family Services Providers, told MHW.

At the same time, Lampl does not hesitate a bit in asserting that a statewide implementation of Medicaid health homes will happen in Ohio, and that the patients traditionally served in the community mental health system will benefit significantly from it.

“This is critically important for the people we serve,” she said. “It’s lifesaving.”

Pilot initiative

State mental health and Medicaid officials announced last October that Medicaid beneficiaries with serious and persistent mental illness in five Ohio counties would be eligible to management services delivered through the enrollees’ behavioral health provider agency would assist clients in locating a primary care provider and in accessing necessary appointments.

Four providers are participating in the initiative in urban Lucas County (the Toledo area), and one each are participating in Butler County and in a three-county area encompassing Adams, Lawrence and Scioto Counties.

Enhanced Medicaid funding is paying for the start of the initiative, and state officials and stakeholders already are looking at how to ensure sustainability of the effort beyond its first two years. “It would not be fair to do this for two years and then take it away,” Lampl said.

But as the state prepared to usher in a statewide implementation of health homes this fall, proposed regulations that it had advanced earlier this summer met with resistance from the mental health community. Funding concerns were at the heart of the provider and advocacy communities’ worry.

The state proposed a tiered system of funding to support statewide implementation of health homes, with separate per-member per-month rates for the most severely ill clients and clients with a lower level of severity, explained Cheri L. Walter, CEO of the Ohio Association of County Behavioral Health Authorities.

What the provider community was seeing was a scenario where the state would be emphasizing serving the most severely ill clients in the health homes model, but at rates that could not support the services necessary to do so. Lampl said that only by spreading risk across a provider’s service population, including less severely ill clients, could funding be sufficient to meet overall need.

“With the proposed rates, for the 15 percent of the highest-need clients the funding would not be there to serve them,” Lampl said.

Walter told MHW that because state officials have now agreed to review and likely revise the proposed rules, the mental health community is now hearing that a statewide implementation is not likely to occur until at least next March.

Tracy Plouck, director of the Ohio Department of Mental Health and Addiction Services, told MHW that the state is now looking at possibly establishing a risk-adjusted rate that could reflect the case mix of individual provider agencies.

Plouck added that the state is in the process of recalibrating its overall approach, and that officials also want the eventual statewide rollout to target those providers that are most ready to succeed in a more integrated system. That is reportedly how the participating providers in the pilot effort were targeted to launch the concept in Ohio.

Early indications

While the reported results from the pilot communities are largely anecdotal so far, there is certainly some evidence that patients who may have used only community mental health services in the past are seeing the benefit of establishing relationships with primary care providers as well.

Plouck shared information about the Zepf Center in Toledo, where now more than 70 percent of adult clients are actively linked to a primary care provider — an increase of at least 30 percent from the period before the pilot was launched. In addition, states a summary from the Toledo center, “Health home teams have patient registries and therefore have [vastly] more knowledge on the medical needs and overall health of the clients we serve at Zepf than prior to [health homes].”

It is in fact that heightened awareness of community mental health patients’ overall medical needs that arguably has been the biggest eye-opener for pilot participants thus far. “Some have been surprised at the level of previously unrecognized health conditions,” said Lampl, in areas such as high percentages of youths with body mass index (BMI) readings over 30. Common medical illnesses among the seriously mentally ill, such as diabetes and chronic obstructive pulmonary disease (COPD), are of course showing up in high numbers.

What is beginning to happen now that the pilot efforts have been in place for nearly a year is the establishment of innovative wellness programs in the participating agencies.

Plouck said that one provider recently purchased a vacant church and converted it to a wellness center. Fitness classes, healthy eating workshops and activity groups are becoming common offerings in the mental health agencies.

Walter explained that on an individual outcome level, the health homes project is looking at questions such as “Are you managing your diabetes better?” Systemwide, she said, the proof of the initiative’s ultimate level of success will lie in whether it can reduce high-cost hospitalization, as well as emergency room visits for reasons not related to mental health. •